Anterior Segment Ventricular Restoration Apparatus and Method

ABSTRACT

The symptoms of congenital heart failure are addressed in this surgical procedure for mounting a patch in the ventricle of the heart to reduce ventricular volume. Placement of the patch is facilitated by palpating a beating heart to identify akinetic, although normal appearing, tissue. The patch has an oval configuration facilitating return of the heart to a normal apical shape which enhances muscle fiber efficiency and a normal writhing pumping action. The patch includes a semi-rigid ring, and a circumferential rim to address bleeding. Patch placement is further enhanced by creating a Fontan neck and use of pledged sutures. Intraoperative vascularization and valve replacement is easily accommodated. Increased injection fraction, reduced muscle stress, improved myocardial protection, and ease of accurate patch placement are all achieved with this procedure.

CROSS-REFERENCE TO RELATED APPLICATION

This is a continuation application of pending prior application Ser. No.10/214,798, filed on Aug. 7, 2002, which issued on Jun. 6, 2006, as U.S.Pat. No. 7,056,280, which is a continuation application of priorapplication Ser. No. 09/481,755, filed on Jan. 11, 2000, which issued onAug. 27, 2002, as U.S. Pat. No. 6,439,237, which is a continuationapplication of prior application Ser. No. 09/071,817, filed on May 1,1998, which issued on Feb. 15, 2000, as U.S. Pat. No. 6,024,096. Theabove applications/patents are incorporated by reference as though setforth in full.

FIELD OF THE INVENTION

This invention relates generally to surgical methods and apparatus foraddressing ischemic cardiomyopathy, and more specifically to methods andapparatus for restoring the architecture and normal function of amammalian heart.

DISCUSSION OF THE PRIOR ART

The function of a heart in an animal is primarily to deliverlife-supporting oxygenated blood to tissue throughout the body. Thisfunction is accomplished in four stages, each relating to a particularchamber of the heart. Initially deoxygenated blood is received in theright auricle of the heart. This deoxygenated blood is pumped by theright ventricle of the heart to the lungs where the blood is oxygenated.The oxygenated blood is initially received in the left auricle of theheart and ultimately pumped by the left ventricle of the heartthroughout the body. It can be seen that the left ventricular chamber ofthe heart is of particular importance in this process as it is reliedupon to pump the oxygenated blood initially through a mitral valve intoand ultimately throughout the entire vascular system.

A certain percentage of the blood in the left ventricle is pumped duringeach stroke of the heart. This pumped percentage, commonly referred toas the ejection fraction, is normally about sixty percent. It can beseen that in a heart having a left ventricular volume such as seventymilliliters, an ejection fraction of sixty percent would deliverapproximately 42 milliliters of blood into the aorta.

Realizing that the heart is part of the body tissue, and the heartmuscle also requires oxygenated blood, it can be appreciated that thenormal function of the heart is greatly upset by clotting or closure ofthe coronary arteries. When the coronary arteries are blocked, anassociate portion of the heart muscle becomes oxygen-starved and beginsto die. This is clinically referred to as a heart attack. Ischemiccardiomyopathy typically occurs as the rest of the heart dilates in anattempt to maintain the heart's output to the body.

As the ischemic cardiomyopathy progresses, the various structures of theheart are progressively involved including the septum, the apex and theantero-ateral wall of the left ventricle. Within a particular wall, theblood starvation begins at the inside of the wall and progresses to theoutside of the wall. It can be seen that addressing ischemiccardiomyopathy shortly after the heart attack can limit the detrimentaleffects to certain elements of the heart structure, as well as the innermost thicknesses of the walls defining those structures.

As a heart muscle is denied blood nourishment support, its ability toparticipate, let alone aid, in the cardiac pumping function, is greatlydiminished and typically nil. Such muscle is commonly referred to asakinetic, meaning it does not move. In some cases the wall will formelastic scar tissue which tends to balloon in response to the pumpingaction. This muscle tissue is not only akinetic, in that it does notcontribute to the pumping function, but it is in fact dyskinetic, inthat it detracts from the pumping function.

Perhaps the most notable symptom of ischemic cardiomyopathy is thereduction in the ejection fraction which may diminish, for example, froma normal sixty percent to only twenty percent. This results clinicallyin fatigue, and inability to do stressful activities, that require anincrease in output of blood from the heart. The normal response of theheart to a reduction in ejection fraction is to increase the size of theventricle so that the reduced percentage continues to deliver the sameamount of oxygenated blood to the body. By way of example, the volume ofthe left ventricle may double in size. Furthermore, a dilated heart willtend to change its architecture from the normal conical or apical shape,to a generally spherical shape. The output of blood at rest is keptnormal, but the capacity to increase output of blood during stress(i.e., exercise, walking) is reduced. Of course, this change inarchitecture has a dramatic effect on wall thickness, radius, and stresson the heart wall. In particular, it will be noted that absent thenormal conical shape, the twisting motion at the apex, which can accountfor as much as one half of the pumping action, is lost. As aconsequence, the more spherical architecture must rely almost totally onthe lateral squeezing action to pump blood. This lateral squeezingaction is inefficient and very different from the more efficienttwisting action of the heart. The change in architecture of the heartwill also typically change the structure and ability of the mitral valveto perform its function in the pumping process. Valvular insufficiencycan also occur due to dilatation.

Although the dilated heart may be capable of sustaining life, it issignificantly stressed and rapidly approaches a stage where it can nolonger pump blood effectively. In this stage, commonly referred to ascongestive heart failure, the heart becomes distended and is generallyincapable of pumping blood returning from the lungs. This furtherresults in lung congestion and fatigue. Congestive heart failure is amajor cause of death and disability in the United States whereapproximately 400,000 cases occur annually.

Following coronary occlusion, successful acute reprefusion bythrombolysis, (clot dissolution) percutaneous angioplasty, or urgentsurgery can decrease early mortality by reducing arrhythmias andcardiogenic shock. It is also known that addressing ischemiccardiomyopathy in the acute phase, for example with reperfusion, maysalvage the epicardial surface. Although the myocardium may be renderedalinetic, at least it is not dyskinetic. Post-infarction surgicalre-vascularation can be directed at remote viable muscle to reduceischemia. However, it does not address the anatomical consequences ofthe akinetic region of the heart that is scarred. Despite thesetechniques for monitoring ischemia, cardiac dilation and subsequentheart failure continue to occur in approximately fifty percent ofpost-infarction patients discharged from the hospital.

Various surgical approaches have been taken primarily to reduce theventricular volume. This is also intended to increase the ejectionfraction of the heart. In accordance with one procedure, viable muscleis removed from the heart in an attempt to merely reduce its volume.This procedure, which is typically accomplished on a beating heart, hasbeen used for hearts that have not experienced coronary disease, butnevertheless, have dilated due to leaking heart valves. Other attemptshave been made to remove the scarred portion of the heart and to closethe resulting incision. This has also had the effect of reducing theventricular volume.

In a further procedure, a round, circular patch has been proposed forplacement typically in the lateral ventricular wall. Unfortunately,providing the patch with a circular shape has allowed the dilated heartto remain somewhat enlarged with a thin and overstressed wall section.The exact placement of the patch has been visually determined using onlya visual indication where the typically white scar tissue meets thetypically red normal tissue. Location of the patch has been facilitatedin a further procedure where a continuous suture has been placed aroundthe ventricular wall to define a neck for receiving the patch. The neckhas been formed in the white scar tissue rather than the soft viablemuscle. This procedure has relied on cardioplegia methods to stop thebeating of the heart and to aid in suture placement.

These surgical procedures have been met with some success as theejection fraction has been increased, for example, from twenty-fourpercent to forty-two percent. However, despite this level of success,little attention has been paid to myocardial protection, the potentialfor monitoring the writhing action associated with apical structure, orthe preferred structure for the patch. Failure to protect the heartduring restoration of the segment has increased hospital mortality,morbidity, and irreversibly damaged some normal muscle needed tomaintain the heart's output.

SUMMARY OF THE INVENTION

The procedure of the present invention is preferably performed on abeating heart. This is believed to greatly improve the myocardialprotection during the restoration process. The procedure furtherbenefits from the beating of the heart by providing a palpableindication of preferred patch placement. As opposed to prior procedures,the primary intent is to exclude, not only the budging dyskineticsegments, but also the non-contracting akinetic segments of the heartwhich do not contribute to the pumping action. As a result, akineticsegments, despite a normal visual appearance, can be included forremoval in this procedure. The process may include an endoventriclarFontan suture, but the stitch will typically be placed in normal tissuewith palpable guidance rather than in scar tissue and only a visualdetermination.

A non-circular, anatomically-shaped, typically oval patch is proposedand may be formed of a sheet material such as mammalian fixedpericardium. The patch may include a continuous ring which separates thebody of the material from a hemostatic rim or flange which facilitatesbleeding control. The patch is fixed to the Fontan neck preferably usingpledgeted, interrupted sutures to secure patch placement and avoiddistortion. Closure of the excluded ventricle over the hemostatic patchavoids dead space and provides security against patch leaks andresulting expansion.

These and other features and advantages of the invention will becomemore apparent with a description of preferred embodiments and referenceto the associated drawings.

DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of the abdominal cavity of a human bodyshowing the heart in cross section;

FIG. 2 is a front plan view of the heart showing coronary arteries whichfeed the septum, apex and lateral wall of the myocardium;

FIG. 3 is a axial cross section view of the ventricular portions of theheart illustrating a dilated, generally spherical left ventricle;

FIG. 4 is an anterior elevation view of the heart with an incision intothe left ventricle through dyskinetic scar tissue;

FIG. 5 is an anterior elevation view similar to FIG. 4 where theincision is made in marbled akinetic tissue;

FIG. 6 is an anterior elevation view similar to FIG. 5 illustrating theincision made in normal-looking akinetic tissue;

FIG. 7 is a axial cross section view of the left ventricle showing thesurgeon's hand palpating the myocardium to define an imaginarycircumferential line of separation between viable and akinetic tissue;

FIG. 8 is a axial cross section view similar to FIG. 7 illustrating thepalpating heart and a preferred zone of placement for a patch associatedwith the present invention;

FIG. 9 is an anterior elevation view similar to FIG. 4 and illustratingplacement of a Fontan stitch in the ventricular wall;

FIG. 10 is an axial cross section view illustrating a Fontan neckcreated by the Fontan stitch;

FIG. 11 is a side elevation view of the opening illustrated in FIG. 9with the Fontan suture tightened to facilitate the natural ovalformation of the opening;

FIG. 12A is a plan view of sheet material included in one embodiment ofthe patch associated with the present invention;

FIG. 12B is a cross section view taken along lines 12B-12B of FIG. 12Aand illustrating the sheet material in a concave configuration;

FIG. 13 is a top plan view of a ring associated with the patch of thepresent invention;

FIG. 14 is a circumferential cross section taken along lines 14-14 ofFIG. 13;

FIG. 15 is a top plan view showing the sheet material and ring combinedto form one embodiment of the patch of the present invention;

FIG. 16 is a cross section view of the patch taken along lines 16-16 ofFIG. 15;

FIG. 17 is a cross section view similar to FIG. 12B and illustrating thesheet material in a convex configuration;

FIG. 18 is a cross section view similar to FIG. 16 and illustrating thering disposed on a concave surface of the sheet material;

FIG. 19 is a cross section view similar to FIG. 18 and illustrating thering sandwiched between two pieces of the sheet material;

FIG. 20 is a cross section view similar to FIG. 19 and illustrating thering sandwiched between two pieces of material, but having only a singlelayer in the center of the patch;

FIG. 21 is an anterior elevation view similar to FIG. 11 andillustrating the placement of pledgeted, interrupted sutures engagingthe patch in a remote location;

FIG. 22A is an axial cross section view of the left ventricleillustrating the patch being moved along the interrupted sutures fromthe remote location to the Fontan neck;

FIG. 22B is a perspective view similar to FIG. 21 and illustrating analternative method for placement of interrupted sutures;

FIG. 23 is an axial cross section view similar to FIG. 22 andillustrating the patch in its final disposition against the Fontan neck,and further illustrating use of the hemostatic rim to control bleeding;

FIG. 24 is an axial cross section view of the ventricular portion of theheart, with the patch mounted in place, the ventricle wall restored toits apical configuration, and the lateral ventricular wall closed inoverlapping relationship with the septum wall next to the patch.

DESCRIPTION OF THE PREFERRED EMBODIMENTS AND BEST MODE OF THE INVENTION

Abdominal portions of the human body are illustrated in FIG. 1 anddesignated by the reference numeral 10. The body 10 is merelyrepresentative of any mammalian body having a heart 12 which pumps bloodcontaining nutrients and oxygen, to vitalize tissue in all areas of thebody 10. Other organs of particular importance to this blood circulationprocess include the lungs 14 and 16, and the vasculature of the body 10including arteries which carry blood away from the heart 12 and veinswhich return blood to the heart 12.

The heart 12 typically includes four chambers, a right auricle 18, aright ventricle 21, a left auricle 23 and a left ventricle 25. Ingeneral, the auricles 18 and 23 are receiving chambers and theventricles 21 and 25 are pumping chambers. Each of these chambers 18-25is associated with a respective function of the heart 12. For example,it is the purpose of the right auricle 18 to receive the deoxygenatedblood returning in the veins of the body 10, such as the femoral vein27. From the right auricle 18, the deoxygenated blood passes into theright ventricle 21 from which it is pumped through a pulmonary artery 30to the lungs 14 and 16.

Within the lungs 14 and 16, the deoxygenated blood is reoxygenated andreturned to the left auricle 23 of the heart 12 through a pulmonary vein32. From this chamber, the oxygenated blood passes through a mitralvalve 34 into the left ventricle 25. With each beat of the heart 12, theleft ventricle 25 contracts pumping the oxygenated blood into thearteries of the body, such as the femoral artery 36.

The shape of the normal heart 12 is of particular interest as itdramatically affects the way that the blood is pumped. It will be noted,for example, that the left ventricle 25, which is the primary pumpingchamber, is somewhat elliptical, conical or apical in shape in that itis longer than it is wide and descends from a base 35 with a decreasingcross-sectional circumference, to a point or apex 37. The left ventricle25 is further defined by a lateral ventricle wall 38, and a septum 41which extends between the auricles 18, 23 and the ventricles 21, 25.

The pumping of the blood from the left ventricle 25 is accomplished bytwo types of motion. One of these motions is a simple squeezing motionwhich occurs between the lateral wall 38 and the septum 41 asillustrated by the arrows 43 and 45, respectively. The squeezing motionoccurs as a result of a thickening of the muscle fibers in themyocardium. This compresses the blood in the ventricle chamber 25 andejects it into the body 10. The thickening changes between diastole(before the heart is contracting) and systole (when the heart isejecting). This is seen easily by echocardiogram, and can be routinelymeasured.

The other type of motion is a twisting or writhing motion which beginsat the apex 37 and rises toward the base 35, as shown by the arrow 47.The rising writhing motion occurs because the heart muscle fibers run ina circular or spiral direction around the heart 12. When these fibersconstrict, they cause the heart to twist initially at the small area ofthe apex 37, but progressively and ultimately to the wide area of thebase 35. These squeezing and twisting motions are equally important asthey are each responsible for moving approximately one-half of the bloodpumped.

The amount of blood pumped from the left ventricle 25 divided by theamount of blood available to be pumped is referred to as the ejectionfraction of the heart 12. Generally, the higher the ejection fractionthe more healthy the heart. A normal heart, for example, may have atotal volume of one hundred milliliters and an ejection fraction ofsixty percent. Under these circumstances, 60 milliliters of blood arepumped with each beat of the heart 12. It is this volume of blood in thenormal heart of this example, that is pumped with each beat to providenutrients including oxygen to the muscles and other tissues of the body10.

The muscles of the body, of course, include the heart muscle ormyocardium which defines the various chambers 18-25 of the heart 12.This heart muscle also requires the nutrients and oxygen of the blood inorder to remain viable. With reference to FIG. 2, it can be seen thatthe anterior or front side of the heart 12 receives oxygenated bloodthrough a common, artery 58 which bifurcates into a septal artery branch52, which is directed toward the septum 41, and an anterior descendingartery 54 which is directed toward the apex 37 and the lateral ventriclewall 38.

When a blockage occurs in one of these coronary arteries, that portionof the heart muscle which is fed by the blocked artery no longerreceives the oxygen needed to remain viable. These blockages typicallyoccur in the common artery 58 and in the septal artery branch 52. Whenthe common artery is involved, the septum 41, apex 37 and lateral wall38 all become ischemic or oxygen deprived. When only the septal arterybranch 52 is involved, the ischemic symptoms are limited primarily tothe septum 41 and the apex 37. In this latter case, the septum 41 isalmost always affected, the apex 31 is usually affected, and the lateralwall 38 is sometimes affected.

As the ischemia progresses through its various stages, the affectedmyocardium dies losing its ability to contribute to the pumping actionof the heart. The ischemic muscle is no longer capable of contracting soit cannot contribute to either squeezing or the twisting motion requiredto pump blood. This non-contracting tissue is said to be akinetic. Insevere cases the akinetic tissue, which is not capable of contracting,is in fact elastic so that blood pressure tends to develop a bulge orexpansion of the chamber. This is particularly detrimental as thelimited pumping action available, as the heart 12 loses even more of itsenergy to pumping the bulge instead of the blood.

The body's reaction to ischemic infarction is of particular interest.The body 10 seems to realize that with a reduced pumping capacity, theejection fraction of the heart is automatically reduced. For example,the ejection fraction may drop from a normal sixty percent to perhapstwenty percent. Realizing that the body still requires the same volumeof blood for oxygen and nutrition, the body causes its heart to dilateor enlarge in size so that the smaller ejection fraction pumps about thesame amount of blood. As noted, a normal heart with a blood capacity ofseventy milliliters and an ejection fraction of sixty percent would pumpapproximately 42 milliliters per beat. The body seems to appreciate thatthis same volume per beat can be maintained by an ejection fraction ofonly thirty-percent if the ventricle 25 enlarges to a capacity of 140milliliters. This increase in volume, commonly referred to as“remodeling” not only changes the volume of the left ventricle 25, butalso its shape. The heart 12 becomes greatly enlarged and the leftventricle 25 becomes more spherical in shape losing its apex 37 asillustrated in FIG. 3. In this view, the stippled area of cross sectionshows the ischemic or infracted region of the myocardium.

On the level of the muscle fibers, it has been noted that dilation ofthe heart causes the fibers to reorient themselves so that they aredirected away from the inner heart chamber containing the blood. As aconsequence, the fibers are poorly oriented to accomplish even thesqueezing action as the lines of force become less perpendicular to theheart wall. It will be noted that this change in fiber orientationoccurs as the heart dilates and moves from its normal elliptical shapeto its dilated spherical shape. The spherical shape further reducespumping efficiency since the fibers which normally encircle the apex tofacilitate writhing are changed to a more flattened formation as aresult of these spherical configurations. The resulting orientation ofthese fibers produce lines of force which are also directed laterally ofthe ventricle chamber 25. Thus, the dilation and resulting sphericalconfiguration greatly reduces contraction efficiency.

Although the remodeling of the heart 12 by the body 10 helps inmaintaining the blood flow, it places the heart wall under considerablestress which eventually can result in congestive heart failure. Whilemyocardial ischemia or infarction is the primary cause of death anddisability in this country, congestive heart failure is certainly thesecondary cause with over 400,000 cases reported annually. It is thispost-infarction congestive heart failure which is a primary focus of thepresent invention.

As noted, successful acute reprefusion by thrombolysis, percutaneousangioplasty, or urgent surgery can decrease early mortality by reducingarrhythmia and cariogenic shock. These procedures applied in the earlystages of ischemia can also aid in salvaging the epicardial surface ofthe myocardium and thereby prevent akinetic tissue from becomingdyskinetic. Notwithstanding these known methods of intervention, cardiacdilation and subsequent congestive heart failure occur in approximatelyfifty percent of the post-infarction patients.

The procedure of the present invention addresses the effects myocardialinfarction using a cardioprotective approach to restore the geometry ofthe left ventricle. This is not a “remodeling” procedure automaticallyproduced by the body 10, nor a “reconstructive” procedure which leavesthe heart with other than a normal geometry. Rather, this is a procedurewhich attempts to “restore” the normal geometry, and particularly theapical configuration of the left ventricle 25. The procedure reduces thevolume of the left ventricle 25, but also increases the percentage ofthe ventricle wall which is viable. This greatly increases the ejectionfraction of the heart and significantly reduces heart stress.

With a primary purpose of reducing the left ventricle volume, the intentof the procedure initially is to remove that portion of the wall whichis not capable of contracting. This, of course, includes the scarreddyskinetic segments, which are easy to visualize, but may also includeakinetic segments, which do not contract despite their normalappearances.

An incision 61 is cut into the myocardial wall of the dilated heart 12as illustrated in FIG. 4. If the surrounding tissue is dyskinetic, itwill typically be formed entirely of thin, elastic scar tissue. It isthe elasticity of this scar tissue which causes the detrimentalballooning or bulging effects previous discussed.

In some cases, the tissue surrounding the incision 61 will be somewhatmarbled as illustrated in FIG. 5 with patches of both scar tissue 63 andviable red tissue 65. This marbled tissue is often characterized bytrabeculae 67 which form ridges along the inner surface or endotheliumof the wall. In spite of the presence of some viable tissue 65, thesemarbled walls of the heart 12 may nevertheless be akinetic.

With reference to FIG. 6, it is apparent that the akinetic portion ofthe myocardium may even appear to be viable with an absence of whitescar tissue and the presence of a full red color. Nevertheless, theseportions are akinetic and offer no positive effect to the pumpingprocess.

Given these factors, it is apparent that a determination as to where theakinetic portions begin and end cannot be a visual determination asrelied on by the prior art. Although the visual appearance may be ofsome value in this determination, ultimately, one must palpate thetissue as illustrated in FIG. 7. Note that this emphasizes theimportance of performing the restorative surgery on a beating heart. Bypalpating the myocardial wall, one can feel where the contractions ofthe lateral ventricular wall 38 and the septum 41 begin and end. Withoutregard for color or other properties visually distinguishable, thepalpating will usually indicate viable tissue on one side of animaginary circumferential line 70, with akinetic and dyskinetic tissueon the other side of the imaginary line 70. As described in greaterdetail below, a patch 72 will ultimately be positioned relative to thisimaginary circumferential line 70 not only to reduce the volume of theleft ventricle 25 but also to define that reduced volume with a largerpercentage of viable heart muscle.

After the preferred location of the patch 72 has been determinedrelative to the circumferential line 70, a continuous Fontan stitch 74can be placed in proximity to the line 70 as illustrated in FIG. 9. Thisstitch 74 produces an annular protrusion 76 which forms a neck 78relative to the imaginary line 70. This neck 78 initially may have around circular configuration as illustrated in FIG. 9. However, as thesuture 74 is tightened, the musculature of the myocardium will form anatural oval shape as illustrated in FIG. 11. It is this oval-shapedneck 78, formed by the Fontan stitch 74, which in its natural ovoidshape is particularly adapted to receive the patch 72 of the presentinvention.

Providing the patch 72 with a configuration complimentary to the ovoidshape of the Fontan stitch 74 is believed to be of particular importanceand advantage to the present invention. In the past, patches of a round,circular form were used. This form maintained the dilatation of stretchfibers in their more inefficient transverse orientation. As a result,the fiber contraction continued to be very inefficient. Providing thepatch 72 with an oval configuration restores the apex 37 or ellipticalform of the heart 12. On a muscle fiber level, the fibers are directedback to a more normal, meaning generally perpendicular, orientation withrespect to the heart wall 38. This reorients the lines of contractionforce to greatly increase the contraction efficiency.

Construction of various embodiments of the patch 72 are discussed withreference to FIGS. 12A-20. In the plan view of FIG. 12A, a sheetmaterial 81 is illustrated to have the shape of an ellipse with a majoraxis 83 between 30 and 50 millimeters and a minor axis 85 between 20 and30 millimeters. It is contemplated that the sheet material 81 can beprovided in two sizes, such as 20×30 millimeters and 30×40 millimeters.

The sheet material 81 may be formed, for example, from Dacron(Hemashield), or polytetrafluroethylene (Gortex). However in a preferredembodiment, the sheet material 81 is formed of autologous pericardium,orsome other fixed mammalian tissue such as bovine or porcine pericardium.Importantly, the sheet material 81 is preferably sized and configuredwith a shape similar to that of the Fontan neck 78 as illustrated inFIG. 11. As noted, this shape is non-circular and preferably oval.

The sheet material 81 can have a generally flat planar configuration,can be shaped as a section of a sphere, or an elliptical configuration.The spherical shape can be achieved as illustrated in FIG. 12B by fixingthe pericardium while it is stretched over a spherical die to form aconcave surface 91, and the elliptical configuration can be achieved byfixing the pericardium while it is stretched over an elliptical die toform an elliptical configuration.

In addition to the sheet material 81, the patch 72 also preferablyincludes a ring 87 which will typically have a toroidal configurationwith a circumferential cross section that is circular, as shown in FIG.13. The ring will typically be formed of a plastic graph material thatcan also be made of curled autogenous tissue such as fascia orpericardium. In general, the ring 87 can be formed from anybiocompatible material having a degree of flexibility suitable toprevent interference with the normal contractions of the heart 12.

The circumferential cross section view of FIG. 14 illustrates that thering 87 may be enclosed in a tubular sheath 90 which may be formed fromwoven Dacron, and incorporated to promote tissue ingrowth to the patch72.

The ring 87 will generally have a non-circular shape which may besimilar to but smaller than the shape of the material 81. Providing thering 87 with a shape similar to the material 81 will enable the ring 87to be attached to the material 81 as illustrated in FIGS. 15 and 16 witha body 92 of the patch disposed within the ring 87, and acircumferential rim or flange 93 disposed outwardly of the ring 87. Therim 93 will preferably have a constant width around its circumference.This width will typically be in a range between 5 and 8 millimeters.

Many variations on the patch 72 will be apparent from the foregoingdiscussion. For example, as illustrated in FIG. 17, the sheet material81 can be provided with a convex surface 95 facing the left ventricle 25rather than the concave surface illustrated in FIG. 13. As illustratedin FIGS. 16 and 18, the ring 87 can be disposed on either the interioror exterior side of the material 81.

With reference to FIG. 18, the ring 87 can be attached to the material81 by adhesive or by stitches 97 passing over the ring 87 and throughthe material 81. Alternatively, with the reference to FIG. 19, the ring87 can be sandwiched between two pieces of the sheet material. In thiscase, a second piece of the sheet material 99 can be positioned on theside of the ring 87 opposite to the sheet material 81. Appropriatesutures extending around the ring 87 and through the materials 81 and 99will sandwich the ring and maintain it in the preferred position. Withreference to FIG. 20, the second piece of material 99 can be formed as acircle with an inner diameter 100 less than that of the ring 87, and aouter diameter 102 generally equal to that of the material 81.

It will be appreciated that many variations on these preferredembodiments of the patch 82 will be apparent, each having a generallynon-circular sheet material, such as the material 81, and perhaps asomewhat flexible toroid or oval ring 87.

In a preferred method for placing the patch 72, interrupted sutures 105can be threaded through the Fontan neck 78 as illustrated in FIG. 21.Where the tissue is soft, the sutures 105 can be looped through pledgets110 on the interior side of the neck 78 with the free ends of thesutures 105 extending through the exterior side of the neck 78. Thesefree ends, emanating from progressive positions around thecircumferential neck 78, are passed in complementary positions throughthe body of the patch 72 which is initially positioned remotely of theneck 78 as illustrated in FIG. 21. Since the Fontan stitch 74 may beapplied to normal (although akinetic) tissue, the pledgets 110 arepreferred to insure that the sutures 105 are well anchored in the neck78.

Another method for placement of the interrupted patch suture isillustrated in FIGS. 22A and 22B. In this view, which is similar to FIG.2, interrupted sutures 111 are directed through the entire ventricularwall 38 and exit the wall 38 in proximity to the protrusion 76 whichforms the Fontan neck 78. These sutures 111 can also be anchored in apledget strip 113 disposed on the outer surface of the heart 12 tofurther enhance the anchoring of these sutures 111.

When all of the interrupted sutures 105 have been placed around thecircumference of the neck 78, the patch 72 can be moved from its remotelocation along the sutures 105 and into proximity with the oval neck 78.This step is illustrated in FIG. 22A where the patch 72 is embodied withthe concave surface 91 facing the neck 78 and with the ring 87 disposedoutwardly of the material 81. After the patch 72 has been moved into anabutting relationship with the neck 78, the interrupted sutures 105 canbe tied as illustrated in FIG. 23.

Having closed the left ventricular cavity 25 with the patch 72, one mayproceed to address any bleeding which may have resulted from placementof the Fontan stitch 74 or the sutures 105. Such bleeding is illustratedby the reference numeral 112 in FIG. 23. This bleeding 112 willtypically occur in close proximity to the neck 78 and beneath the regioncovered by the rim or flange 93 associated with the material 81 of thepatch 72. This bleeding can normally be stopped by merely placing asuture through the ventricular wall 38 and the rim 93 at the point ofbleeding. A pledget 114 can be used to tie the suture 112 with the rim93 closely held against the bleeding wall 38. This reinforcing stitch,acting in combination with the rim 93 of the patch 72, will usually stopany bleeding associated with the sutures.

With the patch 72 suitably placed, the operative site can be closed byjoining the myocardial walls in a vest-over-pants relationship asillustrated in FIG. 24. Care should be taken not to distort the rightventricle 21 by folding the septum wall 41 over the ventricular wall 38.Alternatively, the lateral wall 38 can be disposed interiorly of theseptum wall 41 so a majority of the force on the patch 72 is diverted tothe lateral wall 38. These walls 38 and 41 can be overlapped in closeproximity to the patch 72 in order to avoid creating any cavity betweenthe patch 72 and the walls 38, 41. When air evacuation is confirmed bytransesophageal echo, the patient can be weaned off bypass usually withminimal, if any, inotropic support. Decanulasation and closure isroutine.

FIG. 24 is positioned in proximity to FIG. 3 in order to illustrate thedramatic difference between the pre-operative dilated heart of FIG. 3and the post-operative apical heart of FIG. 24. For comparison it willagain be noted that the dilated heart of FIG. 3 might typically have aleft ventricular volume of 140 milliliters which might produce a bloodflow of 42 milliliters with an ejection fraction of 30%. Comparing thiswith the postoperative heart of FIG. 24, it can be seen initially thatthe ventricular volume is reduced for example to 90 milliliters. Thepercentage of viable heart wall as opposed to akinetic heart wall isgreatly increased thereby providing an increase in the ejectionfraction, for example from thirty percent to forty-five percent. Thiscombination results in a pumped blood volume of about 40 milliliterswith each beat of the heart 12.

These structural changes are somewhat quantitative in consideration. Buta further advantage, qualitative in nature, is also associated with thepresent procedure. It will be noted that this restorative procedureprovides the heart 12 with a more natural apical configuration whichfacilitates the writhing action discussed with reference to the arrow 47in FIG. 1. Thus, not only is the normal size of the heart achieved, butthe restoration procedure also achieves a normal heart operation. Incombination, the patch 72 and the resulting procedure significantlyreduce the long term effects of myocardial ischemia and overcome many ofthe causes associated with congestive heart failure.

It may be found that muscle function will be restored to some remoteareas following the altered ventricular architecture. Although not fullyunderstood, it is believed that this restoration procedure improvesremote segmental myocardial contractility by reducing the wall tensionand stress in the myocardium due to a reduction in ventricular volume.The stress equation states that ${Stress} = \frac{P \times R}{2h}$

-   -   where    -   P is blood pressure;    -   R is radius of the heart wall; and    -   h is wall thickness.

Reducing the ventricular volume decreases the radius, increases thethickness, and thereby reduces wall stress. This improves the myocardialoxygen supply/demand relationship, but may also revive thecontractibility of otherwise normal but previously stressed myocardium.At the very least, the reduced stress on the heart 12 is relieved alongwith any potential for congestive heart failure.

A further advantage of this procedure relates to the incision 61 in theleft ventricle 25 which also provides access to the mitral valve 34.Replacing this mitral valve 34 through the left ventricle 25 is muchsimpler than the present intra-atrial replacement procedure. Coronaryartery bypass grafts also can be more easily accommodatedintraoperatively. As a result, all of these repairs can be undertakenwith greater simplicity and reduced time. While blood cardioplegia maybe advantageously used for revascularization and valvular procedures, itwould appear that the restorative procedure is best accomplished withcontinuous profusion of the beating open heart for cardiac protection.

Placement of patch 70 can be further enhanced by providing in the patchkit a plurality of sizing disks which can be individually held inproximity to the Fontan neck in order to determine appropriate patchsize. The disks might have a generally planar configuration, and ofcourse, would vary in size. Each disk might have a centrally locatedhandle extending from the planar disk for ease of use. The patch 72could be removably mounted on a holder also including a disk, on whichthe patch is mounted, and an elongate handle extending from the disk tofacilitate placement.

As further support for the restoration procedure, a special sutureneedle is contemplated which has a proximal end and a distal end. Theproximal end is generally straight and accounts for more than half ofthe length of the needle. The distal end is curved along a relativelylarge radius facilitating initial penetration of the thick heart wall.With this configuration, the needle can be easily introduced through thethick myocardium, but then pulled along a generally straight path as itis removed interiorly of the ventricle.

The goal of this procedure is to restore the heart 12 to its normalsize, shape and function. This includes restoring the conical apex ofthe heart in order to achieve the writhing pumping action. Thenonfunctioning segmental ventricular myocardium is excluded and replacedwith a patch so that the only akinetic wall of the ventricle is thatdefined by the small patch area. Not only is visual assessment enhanced,but more importantly, palpation affords the surgeon the ability tocarefully and accurately determine the circumferential line ofseparation between the contracting and noncontracting muscle. Thisdetermination is achieved although the muscle may have normal color andmay not contain either circular or trabecular scar tissue.

It is believed that cardioplegia arrest may be deleterious toventricular function in the open ventricle because of nonuniform flowdistribution. By avoiding this cardioplegia arrest and operating on abeating heart, aortic cross clamping as well as the use of inter-aorticballoons and ventricular assist devices can be avoided. Patch placementcan be intraoperatively adjusted guided by echo or radio nucleotidedata. Placement of the patch is further simplified by creation of theFontan neck 78 and use of interrupted felt or pericardial pledgetedsutures 105. The circumferential rim 93 associated with the patch 72facilitates bleeding control without distortion of the patch 72.Finally, using a vest-over-pants closure of the excluded ventricleobliterates dead space and provides security against patch leaks andresultant expansion.

Within these wide objectives and parameters, there will be variations onthe structure of the patch and the methods of restoration. Although thenon-circular configuration of the sheet material and ring are believedto be critical, the shape of the patch 72 may vary widely to provide thebest anatomical fit with the natural shape of the ventricle 25. Thesheet material 81 may be composed of a variety of materials, bothnatural and artificial. These materials may be woven or nonwoven toachieve a desired structure for the sheet material 81. The ring 87 maysimilarly be formed from a variety of materials and provided with avariety of shapes in order to add structure to the patch 72 withoutinterfering with the normal contractions of the heart 12. Variations ofthe steps of the associated restoration method might include mountingthe patch with a convex surface facing the ventricular cavity, use oftissue adhesives are also contemplated for attaching sealing andotherwise fixing the patch 72 to the Fontan neck 78.

Given these wide variations, which are all within the scope of thisconcept, one is cautioned not to restrict the invention to theembodiments which have been specifically disclosed and illustrated, butrather encouraged to determine the scope of the invention only withreference to the following claims.

1-12. (canceled)
 13. A patch assembly adapted for use in cardiac surgeryto change the configuration of a patient's heart, including: a bodyformed of a first sheet of biocompatible material; a ring attached tothe body and having properties for maintaining a predetermined shape ofthe body; and a ring formed of a second sheet of biocompatible materialto facilitate the flexibility and softness of the patch assembly. 14.The patch assembly recited in claim 13, wherein the sheet material is aplastic graft.
 15. The patch assembly recited in claim 13, wherein thesheet material is tissue.
 16. The patch assembly recited in claim 15,wherein the tissue is autologous.
 17. The patch assembly recited inclaim 15, wherein the tissue is facia.
 18. The patch assembly recited inclaim 15, wherein the tissue is pericardium.
 19. The patch assemblyrecited in claim 13, wherein the second sheet material is curled. 20.The patch assembly recited in claim 13, wherein the ring has a generallyovoid configuration.
 21. The patch assembly recited in claim 13, whereinthe ring has one of a generally circular and ovoid cross section.
 22. Apatch assembly adapted for use in cardiac surgery to change theconfiguration of a patient's heart, including: a ring having aparticular shape; a first sheet of biocompatible material disposedinside the ring and attached to the ring; the first sheet of materialhaving a shape geometrically similar to the particular shape of thering; and a second sheet of biocompatible material forming a perimeterflange extending radially outwardly of the ring.
 23. The patch assemblyrecited in claim 22, wherein: the ring in a natural state is disposedgenerally in a single plane; and the flange in the natural state isdisposed generally in the single plane of the ring.
 24. The patchassembly recited in claim 23, wherein the flange has a generallyconstant width around the perimeter of the ring.
 25. The patch assemblyrecited in claim 24, wherein the constant width of the flange is in arange of five millimeters to eight millimeters.
 26. The patch assemblyrecited in claim 22, wherein the second sheet of material is integralwith the first sheet of material.
 27. A patch assembly adapted for usein cardiac surgery to change the configuration of a patient's heart,including: a first sheet of biocompatible material; a second sheet ofbiocompatible material disposed in a generally parallel relationshipwith the first sheet; a ring sandwiched between and having a fixedrelationship with the first sheet of biocompatible material and thesecond sheet of biocompatible material.
 28. The patch assembly recitedin claim 27, wherein at least one of the first sheet and the secondsheet is larger than the ring and forms a flange extending radiallyoutwardly of the ring.
 29. The patch assembly recited in claim 28,wherein the ring is formed of a material including at least one of aplastic graft and tissue.
 30. The patch assembly recited in claim 27,wherein at least one of the first sheet and the second sheet have apredetermined non-planar configuration.